=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336992890
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAURA WITHOLT FNP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/08/2024
-----------------------------------------------------
Last Update Date | 04/08/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 890 W STETSON AVE STE B
-----------------------------------------------------
City | HEMET
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92543-7311
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-764-2495
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 35167 SLATER AVE
-----------------------------------------------------
City | WINCHESTER
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92596-8799
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 95029172
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------